Form Physical Therapy LLC
NPI 1457840290 · Physical Therapist · Roswell, GA
Enrolled with Medicare as Part B Supplier - Physical/Occupational Therapy Group in Private Practice · source: CMS PECOS Public Provider Enrollment (2026.04.01)
Form Physical Therapy LLC is a Physical Therapist organization in Roswell, GA (NPI 1457840290).
Provider details
- NPI number
- 1457840290
- Entity type
- Organization
- Primary specialty
- Physical TherapistRespiratory, Developmental, Rehabilitative and Restorative Service Providers
- Organization subpart
- No
- Authorized official
- Blair Holliday, Owner(678) 936-0821
- License
- PT008864 (GA)
Specialties & taxonomies
Respiratory, Developmental, Rehabilitative and Restorative Service Providers
Profile Score
A profile completeness & documented-activity index — NOT a quality, outcomes, or patient-satisfaction rating.
- Registry tenure38% of score
8 yrs in NPPES registry
- Profile completeness38% of score
100% of core fields populated
- Practice footprint23% of score
1 documented practice location
Signals a provider has no public data for (e.g. Medicare claims) are left out of the score entirely — never counted as zero — so providers without that data are not penalized. See the full formula and weights in our methodology.
Practice location
Mailing address
Registry dates
- Enumerated
- 2018-05-07
- Last updated
- 2018-05-12
Frequently asked questions
- What is Form Physical Therapy LLC's NPI number?
- Form Physical Therapy LLC's National Provider Identifier (NPI) is 1457840290, a unique 10-digit ID issued by CMS for use in standard healthcare transactions.
- What type of organization is Form Physical Therapy LLC?
- Form Physical Therapy LLC is classified in the NPPES registry as Physical Therapist (Respiratory, Developmental, Rehabilitative and Restorative Service Providers).
- Where is Form Physical Therapy LLC located?
- Form Physical Therapy LLC's practice location on file with NPPES is 1295 Hembree Rd Ste A201, Roswell, GA 30076.
- What is Form Physical Therapy LLC's phone number?
- The practice phone number listed in the NPPES registry for Form Physical Therapy LLC is (678) 936-0821.
- Does Form Physical Therapy LLC accept Medicare?
- Form Physical Therapy LLC is approved to bill Medicare according to CMS PECOS enrollment data (2026.04.01). Confirm current participation with the provider before scheduling.
- Who is the authorized official for Form Physical Therapy LLC?
- The authorized official listed on Form Physical Therapy LLC's NPPES record is Blair Holliday, Owner. The authorized official registers and maintains the organization's NPI and is not necessarily its owner.
- Is Form Physical Therapy LLC's NPI active?
- Yes — Form Physical Therapy LLC's NPI (1457840290) is active in the NPPES registry as of the last update on 2018-05-12.
Source: CMS NPPES Data Dissemination (June 2026). NPI Central is not affiliated with CMS. Data is provided as-is from the public registry.